M. Alexander Otto

SAN FRANCISCO – Hepatitis C–associated deaths are now more common in the United States than HIV-related deaths, according to the Centers for Diseases Control and Prevention.

That’s not just due to improved awareness and treatment of HIV. As deaths from HIV have fallen since 1999 to under 13,000 a year, deaths associated with hepatitis C virus (HCV) have climbed to over 15,000. CDC expects that number to jump to about 35,000 annually within 20 years.

Baby boomers – people born between 1945 and 1965 – currently account for about three-quarters of those who die with HCV-infection, which can take years to manifest as liver cancer or fibrosis.

"This is the population we are very concerned about," said Dr. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

As a result, CDC is poised to recommend one-time HCV screening of all baby boomers, which would be in addition to current screening recommendations for injection-drug users and other high-risk populations, as well as those with unexplained alanine aminotransferase (ALT) elevations, among others. An education campaign, dubbed "No More Hepatitis," also is set to launch next year to boost physician and consumer awareness of HCV, said Bryce Smith, Ph.D., a lead health scientist in CDC’s Division of Viral Hepatitis.

The efforts coincide with the May 2011 approval of two new protease inhibitors for HCV, telaprevir (Incivek) and boceprevir (Victrelis). Both significantly improve sustained viral responses when used in conjunction with peginterferon alfa and ribavirin.

More than 30 HCV agents are in development as well, including some in early phase III trials. The hope is that they will further improve responses, reduce pill burdens, shorten current months-long treatment regimens, and perhaps even end the need for concurrent interferon, a cause of substantial adverse events.

"I think in the next few years, we’ll see a lot of drugs approved," Dr. Liang said.

Meanwhile, "the index of suspicion for hepatitis C infection should be much higher," said Dr. Scott Holmberg, a branch chief in CDC’s Division of Viral Hepatitis.

The agency estimates that half of HCV infections are undiagnosed, largely because current screening recommendations aren’t often followed. "Even when you have a couple of elevated ALTs, about half the time doctors will not test for" hepatitis infection, he said.

"One of the problems is that if someone is drinking and they have an elevated ALT, doctors will think it’s because of the alcohol. Or if they are taking antiretrovirals or statins, that it’s because of the drug. There’s a tendency to dismiss elevated ALT when in fact it should be triggering a test, no matter what you think it’s caused by," Dr. Holmberg said.

CDC’s estimate of HCV-related deaths is based on a review of 21.8 million death records. Any mention of the virus was counted, regardless if HCV was listed as a primary cause of death or simply one of the person’s health problems.

One physician aware of the findings questioned if, in some cases, the virus may simply have been an incidental finding, as opposed to a cause of death. Dr. Holmberg countered that if anything, CDC underestimated the true extent of HCV-related deaths. Because screening rates are low, the virus might not have been noted in cases of chronic liver failure and other conditions in which it may have played a part.

The agency calculates that about 80 million baby boomers would be screened under its plan, and about 2.68 million infections diagnosed.

That’s millions more people screened, and a million more infections detected, than strategies based on ALT elevations. Even when the expense of the new protease inhibitors is factored in – a course of either can cost tens of thousands of dollars – CDC estimates baby-boomer screening is cost-effective, in line with cervical cancer and cholesterol screening (Ann. Intern. Med. 2011 Nov. 4 [epub ahead of print]).

Baby-boomer screening also would catch HCV-infected people who have normal ALTs, 20%-30% of whom can have significant fibrosis nonetheless.

"What we hope is that [screening] will be integrated" into electronic medical records so providers are prompted to test baby boomers. "We tried to make it as easy as possible," said Dr. Smith.

Dr. Liang, Dr. Smith, and Dr. Holmberg said they have no disclosures.

SAN FRANCISCO – Hepatitis C–associated deaths are now more common in the United States than HIV-related deaths, according to the Centers for Diseases Control and Prevention.

That’s not just due to improved awareness and treatment of HIV. As deaths from HIV have fallen since 1999 to under 13,000 a year, deaths associated with hepatitis C virus (HCV) have climbed to over 15,000. CDC expects that number to jump to about 35,000 annually within 20 years.

Baby boomers – people born between 1945 and 1965 – currently account for about three-quarters of those who die with HCV-infection, which can take years to manifest as liver cancer or fibrosis.

"This is the population we are very concerned about," said Dr. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

As a result, CDC is poised to recommend one-time HCV screening of all baby boomers, which would be in addition to current screening recommendations for injection-drug users and other high-risk populations, as well as those with unexplained alanine aminotransferase (ALT) elevations, among others. An education campaign, dubbed "No More Hepatitis," also is set to launch next year to boost physician and consumer awareness of HCV, said Bryce Smith, Ph.D., a lead health scientist in CDC’s Division of Viral Hepatitis.

The efforts coincide with the May 2011 approval of two new protease inhibitors for HCV, telaprevir (Incivek) and boceprevir (Victrelis). Both significantly improve sustained viral responses when used in conjunction with peginterferon alfa and ribavirin.

More than 30 HCV agents are in development as well, including some in early phase III trials. The hope is that they will further improve responses, reduce pill burdens, shorten current months-long treatment regimens, and perhaps even end the need for concurrent interferon, a cause of substantial adverse events.

"I think in the next few years, we’ll see a lot of drugs approved," Dr. Liang said.

Meanwhile, "the index of suspicion for hepatitis C infection should be much higher," said Dr. Scott Holmberg, a branch chief in CDC’s Division of Viral Hepatitis.

The agency estimates that half of HCV infections are undiagnosed, largely because current screening recommendations aren’t often followed. "Even when you have a couple of elevated ALTs, about half the time doctors will not test for" hepatitis infection, he said.

"One of the problems is that if someone is drinking and they have an elevated ALT, doctors will think it’s because of the alcohol. Or if they are taking antiretrovirals or statins, that it’s because of the drug. There’s a tendency to dismiss elevated ALT when in fact it should be triggering a test, no matter what you think it’s caused by," Dr. Holmberg said.

CDC’s estimate of HCV-related deaths is based on a review of 21.8 million death records. Any mention of the virus was counted, regardless if HCV was listed as a primary cause of death or simply one of the person’s health problems.

One physician aware of the findings questioned if, in some cases, the virus may simply have been an incidental finding, as opposed to a cause of death. Dr. Holmberg countered that if anything, CDC underestimated the true extent of HCV-related deaths. Because screening rates are low, the virus might not have been noted in cases of chronic liver failure and other conditions in which it may have played a part.

The agency calculates that about 80 million baby boomers would be screened under its plan, and about 2.68 million infections diagnosed.

That’s millions more people screened, and a million more infections detected, than strategies based on ALT elevations. Even when the expense of the new protease inhibitors is factored in – a course of either can cost tens of thousands of dollars – CDC estimates baby-boomer screening is cost-effective, in line with cervical cancer and cholesterol screening (Ann. Intern. Med. 2011 Nov. 4 [epub ahead of print]).

Baby-boomer screening also would catch HCV-infected people who have normal ALTs, 20%-30% of whom can have significant fibrosis nonetheless.

"What we hope is that [screening] will be integrated" into electronic medical records so providers are prompted to test baby boomers. "We tried to make it as easy as possible," said Dr. Smith.

Dr. Liang, Dr. Smith, and Dr. Holmberg said they have no disclosures.

SAN FRANCISCO – Hepatitis C–associated deaths are now more common in the United States than HIV-related deaths, according to the Centers for Diseases Control and Prevention.

That’s not just due to improved awareness and treatment of HIV. As deaths from HIV have fallen since 1999 to under 13,000 a year, deaths associated with hepatitis C virus (HCV) have climbed to over 15,000. CDC expects that number to jump to about 35,000 annually within 20 years.

Baby boomers – people born between 1945 and 1965 – currently account for about three-quarters of those who die with HCV-infection, which can take years to manifest as liver cancer or fibrosis.

"This is the population we are very concerned about," said Dr. Jake Liang, president of the American Association for the Study of Liver Diseases and chief of the Liver Diseases Branch of the National Institute of Diabetes and Digestive and Kidney Diseases.

As a result, CDC is poised to recommend one-time HCV screening of all baby boomers, which would be in addition to current screening recommendations for injection-drug users and other high-risk populations, as well as those with unexplained alanine aminotransferase (ALT) elevations, among others. An education campaign, dubbed "No More Hepatitis," also is set to launch next year to boost physician and consumer awareness of HCV, said Bryce Smith, Ph.D., a lead health scientist in CDC’s Division of Viral Hepatitis.

The efforts coincide with the May 2011 approval of two new protease inhibitors for HCV, telaprevir (Incivek) and boceprevir (Victrelis). Both significantly improve sustained viral responses when used in conjunction with peginterferon alfa and ribavirin.

More than 30 HCV agents are in development as well, including some in early phase III trials. The hope is that they will further improve responses, reduce pill burdens, shorten current months-long treatment regimens, and perhaps even end the need for concurrent interferon, a cause of substantial adverse events.

"I think in the next few years, we’ll see a lot of drugs approved," Dr. Liang said.

Meanwhile, "the index of suspicion for hepatitis C infection should be much higher," said Dr. Scott Holmberg, a branch chief in CDC’s Division of Viral Hepatitis.

The agency estimates that half of HCV infections are undiagnosed, largely because current screening recommendations aren’t often followed. "Even when you have a couple of elevated ALTs, about half the time doctors will not test for" hepatitis infection, he said.

"One of the problems is that if someone is drinking and they have an elevated ALT, doctors will think it’s because of the alcohol. Or if they are taking antiretrovirals or statins, that it’s because of the drug. There’s a tendency to dismiss elevated ALT when in fact it should be triggering a test, no matter what you think it’s caused by," Dr. Holmberg said.

CDC’s estimate of HCV-related deaths is based on a review of 21.8 million death records. Any mention of the virus was counted, regardless if HCV was listed as a primary cause of death or simply one of the person’s health problems.

One physician aware of the findings questioned if, in some cases, the virus may simply have been an incidental finding, as opposed to a cause of death. Dr. Holmberg countered that if anything, CDC underestimated the true extent of HCV-related deaths. Because screening rates are low, the virus might not have been noted in cases of chronic liver failure and other conditions in which it may have played a part.

The agency calculates that about 80 million baby boomers would be screened under its plan, and about 2.68 million infections diagnosed.

That’s millions more people screened, and a million more infections detected, than strategies based on ALT elevations. Even when the expense of the new protease inhibitors is factored in – a course of either can cost tens of thousands of dollars – CDC estimates baby-boomer screening is cost-effective, in line with cervical cancer and cholesterol screening (Ann. Intern. Med. 2011 Nov. 4 [epub ahead of print]).

Baby-boomer screening also would catch HCV-infected people who have normal ALTs, 20%-30% of whom can have significant fibrosis nonetheless.

"What we hope is that [screening] will be integrated" into electronic medical records so providers are prompted to test baby boomers. "We tried to make it as easy as possible," said Dr. Smith.

Dr. Liang, Dr. Smith, and Dr. Holmberg said they have no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – When police officers are trained to recognize and handle psychiatric emergencies, they are less likely to arrest the mentally ill and more likely to refer them to treatment centers.

And people with mental illness who arrive from police custody are likely to be less agitated, less in need of seclusion and restraints, and more cooperative with initial psychiatric evaluations, "because the officers interact with patients in a very different way compared to most police encounters," said Dr. Michael T. Compton, the lead investigator of a study that evaluated the impact of one such training course, the Memphis Crisis Intervention Team (CIT) program.

Photo (c) Antonprado/iStock.com

Officers who volunteer for the 40-hour program hear lectures about how to recognize mental illness, learn de-escalation techniques, and visit local psychiatric facilities to meet staff and hear first-hand from patients what it’s like for them to deal with the police.

In the study, Dr. Compton asked 183 officers in six Georgia police departments – most around Atlanta and one in Savannah – to record how they resolved encounters with people they suspected were mentally ill, developmentally disabled, or suffering from drug or alcohol problems. In 1,098 encounters over 6 weeks, the 93 officers who went through the training were twice as likely as the 90 who did not to refer those people to treatment, instead of arresting them. The results were statistically significant.

CIT-trained officers logged 517 encounters; 40% ended in referral, and 13% ended in arrests. Among the 183 officers as a whole, 34% of the 1,098 encounters ended in referrals, and 19% ended in arrests. CIT officers also used less force.

The Memphis CIT program is not new; it was launched in 1988 in response to a fatal police shooting in that city. Since then, about 2,400 police departments nationwide have implemented the Memphis model, but sometimes need help training new officers, said Dr. Compton, a professor of psychiatry and behavioral sciences at George Washington University, Washington.

It would help "if mental health providers can volunteer for some of the lectures or to do a site visit because, in a way, police officers are doing part of what ought to be our work; they’re out in the streets performing psychiatric triage," he said.

Officers who were at least 40 years old, and those who had been on the force for at least 10 years were also more likely to refer people to services.

Role playing is central to the de-escalation training; officers learn to actively listen, reflect back what they’re told, and give people plenty of time to answer questions.

They also are taught not to argue against the delusions of acutely psychotic people, but not go along with them, either. Instead, officers learn to pick up on the emotions. They might say something like, " ‘Am I understanding you correctly? It feels like there’s someone following you? That sounds really scary, and you’re really upset. Tell me more about what’s going on and how I may be able to help you,’ " Dr. Compton explained.

The idea is to slow the encounter down so mistakes aren’t made on either side.

Dr. Compton said he has no disclosures.

SAN FRANCISCO – When police officers are trained to recognize and handle psychiatric emergencies, they are less likely to arrest the mentally ill and more likely to refer them to treatment centers.

And people with mental illness who arrive from police custody are likely to be less agitated, less in need of seclusion and restraints, and more cooperative with initial psychiatric evaluations, "because the officers interact with patients in a very different way compared to most police encounters," said Dr. Michael T. Compton, the lead investigator of a study that evaluated the impact of one such training course, the Memphis Crisis Intervention Team (CIT) program.

Photo (c) Antonprado/iStock.com

Officers who volunteer for the 40-hour program hear lectures about how to recognize mental illness, learn de-escalation techniques, and visit local psychiatric facilities to meet staff and hear first-hand from patients what it’s like for them to deal with the police.

In the study, Dr. Compton asked 183 officers in six Georgia police departments – most around Atlanta and one in Savannah – to record how they resolved encounters with people they suspected were mentally ill, developmentally disabled, or suffering from drug or alcohol problems. In 1,098 encounters over 6 weeks, the 93 officers who went through the training were twice as likely as the 90 who did not to refer those people to treatment, instead of arresting them. The results were statistically significant.

CIT-trained officers logged 517 encounters; 40% ended in referral, and 13% ended in arrests. Among the 183 officers as a whole, 34% of the 1,098 encounters ended in referrals, and 19% ended in arrests. CIT officers also used less force.

The Memphis CIT program is not new; it was launched in 1988 in response to a fatal police shooting in that city. Since then, about 2,400 police departments nationwide have implemented the Memphis model, but sometimes need help training new officers, said Dr. Compton, a professor of psychiatry and behavioral sciences at George Washington University, Washington.

It would help "if mental health providers can volunteer for some of the lectures or to do a site visit because, in a way, police officers are doing part of what ought to be our work; they’re out in the streets performing psychiatric triage," he said.

Officers who were at least 40 years old, and those who had been on the force for at least 10 years were also more likely to refer people to services.

Role playing is central to the de-escalation training; officers learn to actively listen, reflect back what they’re told, and give people plenty of time to answer questions.

They also are taught not to argue against the delusions of acutely psychotic people, but not go along with them, either. Instead, officers learn to pick up on the emotions. They might say something like, " ‘Am I understanding you correctly? It feels like there’s someone following you? That sounds really scary, and you’re really upset. Tell me more about what’s going on and how I may be able to help you,’ " Dr. Compton explained.

The idea is to slow the encounter down so mistakes aren’t made on either side.

Dr. Compton said he has no disclosures.

SAN FRANCISCO – When police officers are trained to recognize and handle psychiatric emergencies, they are less likely to arrest the mentally ill and more likely to refer them to treatment centers.

And people with mental illness who arrive from police custody are likely to be less agitated, less in need of seclusion and restraints, and more cooperative with initial psychiatric evaluations, "because the officers interact with patients in a very different way compared to most police encounters," said Dr. Michael T. Compton, the lead investigator of a study that evaluated the impact of one such training course, the Memphis Crisis Intervention Team (CIT) program.

Photo (c) Antonprado/iStock.com

Officers who volunteer for the 40-hour program hear lectures about how to recognize mental illness, learn de-escalation techniques, and visit local psychiatric facilities to meet staff and hear first-hand from patients what it’s like for them to deal with the police.

In the study, Dr. Compton asked 183 officers in six Georgia police departments – most around Atlanta and one in Savannah – to record how they resolved encounters with people they suspected were mentally ill, developmentally disabled, or suffering from drug or alcohol problems. In 1,098 encounters over 6 weeks, the 93 officers who went through the training were twice as likely as the 90 who did not to refer those people to treatment, instead of arresting them. The results were statistically significant.

CIT-trained officers logged 517 encounters; 40% ended in referral, and 13% ended in arrests. Among the 183 officers as a whole, 34% of the 1,098 encounters ended in referrals, and 19% ended in arrests. CIT officers also used less force.

The Memphis CIT program is not new; it was launched in 1988 in response to a fatal police shooting in that city. Since then, about 2,400 police departments nationwide have implemented the Memphis model, but sometimes need help training new officers, said Dr. Compton, a professor of psychiatry and behavioral sciences at George Washington University, Washington.

It would help "if mental health providers can volunteer for some of the lectures or to do a site visit because, in a way, police officers are doing part of what ought to be our work; they’re out in the streets performing psychiatric triage," he said.

Officers who were at least 40 years old, and those who had been on the force for at least 10 years were also more likely to refer people to services.

Role playing is central to the de-escalation training; officers learn to actively listen, reflect back what they’re told, and give people plenty of time to answer questions.

They also are taught not to argue against the delusions of acutely psychotic people, but not go along with them, either. Instead, officers learn to pick up on the emotions. They might say something like, " ‘Am I understanding you correctly? It feels like there’s someone following you? That sounds really scary, and you’re really upset. Tell me more about what’s going on and how I may be able to help you,’ " Dr. Compton explained.

The idea is to slow the encounter down so mistakes aren’t made on either side.

Dr. Compton said he has no disclosures.

SAN FRANCISCO – A simple questionnaire can pick up obstructive sleep apnea in psychiatric patients, according to a small study.

Screening is rare in psychiatric patients at present, but it’s important to diagnose obstructive sleep apnea (OSA) because it can make mental illness worse, contributing to depression and possibly to the risk of manic episodes. Symptoms can mimic mental illness as well, making patients irritable and tired, and OSA makes the use of benzodiazepines and other respiratory depressants problematic, said lead investigator Dr. Vanita Jain, a psychiatry department resident at the University of Utah, Salt Lake City.

"Sleep problems are so integral to psychiatric problems, [and] we wanted to make sure that along with psychiatric disorders, we were treating obstructive sleep apnea, too," she said.

The researchers screened 85 adult community hospital psychiatric inpatients with the STOP-Bang questionnaire, which is typically used as a presurgery screen and takes less than 2 minutes to fill out.

"Sleep problems are so integral to psychiatric problems."

The name refers to the survey’s eight yes/no questions: Do you snore loudly?, Do you often feel tired, fatigued, or sleepy during daytime?, Has anyone observed you stop breathing during your sleep?, Do you have or are you being treated for high blood pressure?, Body mass index more than 35 kg/m²?, Age over 50 years old?, Neck circumference greater than 40 cm?, and Gender male?

Most of the 85 subjects were white, and more than half were men. In all, 46 of the subjects answered yes to at least three of the questions, which is considered a positive screen.

Those patients had overnight pulse oximetry monitoring; 26 desaturated more than 10 times per hour. Fifteen of the 26 – most of the rest had been discharged or refused additional testing – underwent a polysomnography sleep study. Fourteen were ultimately diagnosed with OSA; three had more than 30 apneic episodes per hour.

They would have gone undiagnosed were it not for the questionnaire, Dr. Jain said.

Psychiatric patients can complicate OSA work-up. In the current study, for example, when patients were not coherent enough for an overnight stay in the sleep lab or if they were an escape risk, polysomnography was conducted in their rooms. If patients were "very psychotic or agitated, we just let it be" and asked them to return for an outpatient sleep study, Dr. Jain said.

Treatment options include continuous positive airway pressure (CPAP), special pillows to encourage side or elevated sleeping, dental prostheses to keep the jaw forward during sleep, weight loss, and surgery.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – A simple questionnaire can pick up obstructive sleep apnea in psychiatric patients, according to a small study.

Screening is rare in psychiatric patients at present, but it’s important to diagnose obstructive sleep apnea (OSA) because it can make mental illness worse, contributing to depression and possibly to the risk of manic episodes. Symptoms can mimic mental illness as well, making patients irritable and tired, and OSA makes the use of benzodiazepines and other respiratory depressants problematic, said lead investigator Dr. Vanita Jain, a psychiatry department resident at the University of Utah, Salt Lake City.

"Sleep problems are so integral to psychiatric problems, [and] we wanted to make sure that along with psychiatric disorders, we were treating obstructive sleep apnea, too," she said.

The researchers screened 85 adult community hospital psychiatric inpatients with the STOP-Bang questionnaire, which is typically used as a presurgery screen and takes less than 2 minutes to fill out.

"Sleep problems are so integral to psychiatric problems."

The name refers to the survey’s eight yes/no questions: Do you snore loudly?, Do you often feel tired, fatigued, or sleepy during daytime?, Has anyone observed you stop breathing during your sleep?, Do you have or are you being treated for high blood pressure?, Body mass index more than 35 kg/m²?, Age over 50 years old?, Neck circumference greater than 40 cm?, and Gender male?

Most of the 85 subjects were white, and more than half were men. In all, 46 of the subjects answered yes to at least three of the questions, which is considered a positive screen.

Those patients had overnight pulse oximetry monitoring; 26 desaturated more than 10 times per hour. Fifteen of the 26 – most of the rest had been discharged or refused additional testing – underwent a polysomnography sleep study. Fourteen were ultimately diagnosed with OSA; three had more than 30 apneic episodes per hour.

They would have gone undiagnosed were it not for the questionnaire, Dr. Jain said.

Psychiatric patients can complicate OSA work-up. In the current study, for example, when patients were not coherent enough for an overnight stay in the sleep lab or if they were an escape risk, polysomnography was conducted in their rooms. If patients were "very psychotic or agitated, we just let it be" and asked them to return for an outpatient sleep study, Dr. Jain said.

Treatment options include continuous positive airway pressure (CPAP), special pillows to encourage side or elevated sleeping, dental prostheses to keep the jaw forward during sleep, weight loss, and surgery.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – A simple questionnaire can pick up obstructive sleep apnea in psychiatric patients, according to a small study.

Screening is rare in psychiatric patients at present, but it’s important to diagnose obstructive sleep apnea (OSA) because it can make mental illness worse, contributing to depression and possibly to the risk of manic episodes. Symptoms can mimic mental illness as well, making patients irritable and tired, and OSA makes the use of benzodiazepines and other respiratory depressants problematic, said lead investigator Dr. Vanita Jain, a psychiatry department resident at the University of Utah, Salt Lake City.

"Sleep problems are so integral to psychiatric problems, [and] we wanted to make sure that along with psychiatric disorders, we were treating obstructive sleep apnea, too," she said.

The researchers screened 85 adult community hospital psychiatric inpatients with the STOP-Bang questionnaire, which is typically used as a presurgery screen and takes less than 2 minutes to fill out.

"Sleep problems are so integral to psychiatric problems."

The name refers to the survey’s eight yes/no questions: Do you snore loudly?, Do you often feel tired, fatigued, or sleepy during daytime?, Has anyone observed you stop breathing during your sleep?, Do you have or are you being treated for high blood pressure?, Body mass index more than 35 kg/m²?, Age over 50 years old?, Neck circumference greater than 40 cm?, and Gender male?

Most of the 85 subjects were white, and more than half were men. In all, 46 of the subjects answered yes to at least three of the questions, which is considered a positive screen.

Those patients had overnight pulse oximetry monitoring; 26 desaturated more than 10 times per hour. Fifteen of the 26 – most of the rest had been discharged or refused additional testing – underwent a polysomnography sleep study. Fourteen were ultimately diagnosed with OSA; three had more than 30 apneic episodes per hour.

They would have gone undiagnosed were it not for the questionnaire, Dr. Jain said.

Psychiatric patients can complicate OSA work-up. In the current study, for example, when patients were not coherent enough for an overnight stay in the sleep lab or if they were an escape risk, polysomnography was conducted in their rooms. If patients were "very psychotic or agitated, we just let it be" and asked them to return for an outpatient sleep study, Dr. Jain said.

Treatment options include continuous positive airway pressure (CPAP), special pillows to encourage side or elevated sleeping, dental prostheses to keep the jaw forward during sleep, weight loss, and surgery.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – For the most part, veterans get first-line pharmacotherapy for posttraumatic stress disorder, but Iraq and Afghanistan veterans are less likely than others to finish an adequate 90-day therapeutic trial, especially if they are also depressed, according to an analysis of Veterans Affairs pharmacy records presented at the American Psychiatric Association’s Institute on Psychiatric Services.

Younger, more recent veterans might be too busy with school, jobs, or young families to bother with refills or dose adjustments. They also might not be as aware of mental health issues as older veterans, or as good at navigating the health system, according to lead investigator Dr. Shaili Jain, a psychiatrist at the Palo Alto, Calif., Veterans Affairs (VA) Medical Center and a research fellow at the VA’s National Center for Posttraumatic Stress Disorder.

Whatever the case, the findings "suggest a more vulnerable subtype of veterans," she said. "If I have a vet coming back from Iraq or Afghanistan who has PTSD [posttraumatic stress disorder] and also is pretty depressed, that’s somebody I know I’ve got to watch out for. Maybe I’ll have them come back sooner for an appointment or make sure I am collaborating with" their other doctors to keep them from falling through the cracks. Establishing a strong therapeutic alliance is also essential.

The 482 VA patients in the study all had DSM-IV diagnoses of PTSD. Half served in Iraq or Afghanistan. Their average age was 40; 47% were women, and 69% were white.

"If I have a vet coming back from Iraq or Afghanistan who has PTSD and also is pretty depressed, that’s somebody I know I’ve got to watch out for."

Psychotropic drugs were prescribed to 377; of those, 73% got a first-line treatment, either a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI). Just 61% stayed on the drug for 90 days or longer, judging from whether or not they refilled their prescriptions to cover the full 3 months.

In general, veterans were more likely to be started on an SSRI or SNRI if they were in psychotherapy (odds ratio, 2.51) or had concurrent depression (OR, 7.38).

Iraq and Afghanistan veterans were about half as likely as others to take the drug for 90 days (OR, 0.44); concurrent depression made that even less likely (OR, 0.29).

The results echo previous work finding the group less likely than other vets to use mental health services and more likely to quit a recommended course of psychotherapy early, Dr. Jain said.

To build the therapeutic alliance, "I always try to be cognizant of how important that first impression is. It’s really important to listen to their story" without interrupting or being distracted by a computer screen. It’s also important to tell "patients that we want to see them again and that we can make them better," Dr. Jain said.

Like other people, it is likely that veterans worry about drug side effects. When that’s the case, "I start off with some real basics – that these meds are not going to make you into a zombie. You’re not going to get hooked on them. You’re not going to have to check out of your life because you’re on these meds. Millions of people take them and lead perfectly full and active lives," Dr. Jain said.

Discussion of side effects comes after that point has been made.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – For the most part, veterans get first-line pharmacotherapy for posttraumatic stress disorder, but Iraq and Afghanistan veterans are less likely than others to finish an adequate 90-day therapeutic trial, especially if they are also depressed, according to an analysis of Veterans Affairs pharmacy records presented at the American Psychiatric Association’s Institute on Psychiatric Services.

Younger, more recent veterans might be too busy with school, jobs, or young families to bother with refills or dose adjustments. They also might not be as aware of mental health issues as older veterans, or as good at navigating the health system, according to lead investigator Dr. Shaili Jain, a psychiatrist at the Palo Alto, Calif., Veterans Affairs (VA) Medical Center and a research fellow at the VA’s National Center for Posttraumatic Stress Disorder.

Whatever the case, the findings "suggest a more vulnerable subtype of veterans," she said. "If I have a vet coming back from Iraq or Afghanistan who has PTSD [posttraumatic stress disorder] and also is pretty depressed, that’s somebody I know I’ve got to watch out for. Maybe I’ll have them come back sooner for an appointment or make sure I am collaborating with" their other doctors to keep them from falling through the cracks. Establishing a strong therapeutic alliance is also essential.

The 482 VA patients in the study all had DSM-IV diagnoses of PTSD. Half served in Iraq or Afghanistan. Their average age was 40; 47% were women, and 69% were white.

"If I have a vet coming back from Iraq or Afghanistan who has PTSD and also is pretty depressed, that’s somebody I know I’ve got to watch out for."

Psychotropic drugs were prescribed to 377; of those, 73% got a first-line treatment, either a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI). Just 61% stayed on the drug for 90 days or longer, judging from whether or not they refilled their prescriptions to cover the full 3 months.

In general, veterans were more likely to be started on an SSRI or SNRI if they were in psychotherapy (odds ratio, 2.51) or had concurrent depression (OR, 7.38).

Iraq and Afghanistan veterans were about half as likely as others to take the drug for 90 days (OR, 0.44); concurrent depression made that even less likely (OR, 0.29).

The results echo previous work finding the group less likely than other vets to use mental health services and more likely to quit a recommended course of psychotherapy early, Dr. Jain said.

To build the therapeutic alliance, "I always try to be cognizant of how important that first impression is. It’s really important to listen to their story" without interrupting or being distracted by a computer screen. It’s also important to tell "patients that we want to see them again and that we can make them better," Dr. Jain said.

Like other people, it is likely that veterans worry about drug side effects. When that’s the case, "I start off with some real basics – that these meds are not going to make you into a zombie. You’re not going to get hooked on them. You’re not going to have to check out of your life because you’re on these meds. Millions of people take them and lead perfectly full and active lives," Dr. Jain said.

Discussion of side effects comes after that point has been made.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – For the most part, veterans get first-line pharmacotherapy for posttraumatic stress disorder, but Iraq and Afghanistan veterans are less likely than others to finish an adequate 90-day therapeutic trial, especially if they are also depressed, according to an analysis of Veterans Affairs pharmacy records presented at the American Psychiatric Association’s Institute on Psychiatric Services.

Younger, more recent veterans might be too busy with school, jobs, or young families to bother with refills or dose adjustments. They also might not be as aware of mental health issues as older veterans, or as good at navigating the health system, according to lead investigator Dr. Shaili Jain, a psychiatrist at the Palo Alto, Calif., Veterans Affairs (VA) Medical Center and a research fellow at the VA’s National Center for Posttraumatic Stress Disorder.

Whatever the case, the findings "suggest a more vulnerable subtype of veterans," she said. "If I have a vet coming back from Iraq or Afghanistan who has PTSD [posttraumatic stress disorder] and also is pretty depressed, that’s somebody I know I’ve got to watch out for. Maybe I’ll have them come back sooner for an appointment or make sure I am collaborating with" their other doctors to keep them from falling through the cracks. Establishing a strong therapeutic alliance is also essential.

The 482 VA patients in the study all had DSM-IV diagnoses of PTSD. Half served in Iraq or Afghanistan. Their average age was 40; 47% were women, and 69% were white.

"If I have a vet coming back from Iraq or Afghanistan who has PTSD and also is pretty depressed, that’s somebody I know I’ve got to watch out for."

Psychotropic drugs were prescribed to 377; of those, 73% got a first-line treatment, either a selective serotonin reuptake inhibitor (SSRI) or a serotonin norepinephrine reuptake inhibitor (SNRI). Just 61% stayed on the drug for 90 days or longer, judging from whether or not they refilled their prescriptions to cover the full 3 months.

In general, veterans were more likely to be started on an SSRI or SNRI if they were in psychotherapy (odds ratio, 2.51) or had concurrent depression (OR, 7.38).

Iraq and Afghanistan veterans were about half as likely as others to take the drug for 90 days (OR, 0.44); concurrent depression made that even less likely (OR, 0.29).

The results echo previous work finding the group less likely than other vets to use mental health services and more likely to quit a recommended course of psychotherapy early, Dr. Jain said.

To build the therapeutic alliance, "I always try to be cognizant of how important that first impression is. It’s really important to listen to their story" without interrupting or being distracted by a computer screen. It’s also important to tell "patients that we want to see them again and that we can make them better," Dr. Jain said.

Like other people, it is likely that veterans worry about drug side effects. When that’s the case, "I start off with some real basics – that these meds are not going to make you into a zombie. You’re not going to get hooked on them. You’re not going to have to check out of your life because you’re on these meds. Millions of people take them and lead perfectly full and active lives," Dr. Jain said.

Discussion of side effects comes after that point has been made.

Dr. Jain said she has no disclosures.

SAN FRANCISCO – People who qualify for medical marijuana prescriptions frequently report substituting the substance for their other prescription medications.

In an anonymous survey, 66% of 350 clients at the Berkeley (Calif.) Patients Group, a medical marijuana dispensary, said that they use marijuana as a prescription drug substitute. Their reasons: Cannabis offered better symptom control with fewer side effects than did prescription drugs.

©ron hilton/iStockphoto.com

Those with pain symptoms said that marijuana has less addiction potential than do opioids. Others said marijuana helped to reduce the dose of other medications.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis, and that controls all of those symptoms," said Amanda Reiman, Ph.D., the director of research and social services at the Berkeley center. Almost 50% of those surveyed said they use cannabis two or three times per day.

More than 75% of respondents said they used cannabis for psychiatric disorders, including bipolar disorder, posttraumatic stress disorder, depression, anxiety, and persistent insomnia. Unlike some psychiatric drugs, they said, marijuana didn’t leave them feeling like "zombies," Dr. Reiman reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Almost 70% of those surveyed were men and about 66% were white, in line with the center’s overall demographics. Respondents’ mean age was about 40 years, and ranged from 18 to 81 years. About two-thirds were employed; 81% had at least some college; and 28% made more than $60,000/year. More than half were single.

About 75% had health insurance that covered prescriptions. Even so, "they are still opting to utilize medical cannabis, which is not covered by insurance," Dr. Reiman said.

About 70% said they had a chronic condition, such as diabetes or arthritis. Just over half said they used marijuana for pain relief, including arthritis, migraines, and accident-related injuries. Other uses included appetite stimulation and relief of symptoms from carpal tunnel syndrome and multiple sclerosis.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis."

The amounts used – typically 3-8 g per week – were fairly stable with about 70% reporting no change in marijuana use in the past 6 months. Most "experience a stable level of use throughout their entire course of treatment," Dr. Reiman said.

In operation for 12 years, the Berkeley Patients Group has more than 6,000 patients who pay $15-$60 for one-eighth of an ounce of marijuana – 3.5 grams – depending on strain and potency.

To buy, patients must have a letter from their doctor recommending marijuana for a medical condition. Center staff verifies the letter with a call to the physician. The center obtains the marijuana from its own patients – a must under California law – who grow it and sell it to the dispensary.

Besides smokable marijuana, BPG offers cannabis-laced edibles, capsules, and extract drops to put under the tongue or in tea or coffee, as well as topical marijuana cream for pain and inflammation relief, Dr. Reiman said.

Money remaining after operational costs is used to provide free marijuana to those who couldn’t otherwise afford it, as well as free counseling, message, and other services to BPG members. The dispensary functions more like a community center than a pharmacy, and has a large lounge and regular social events like bingo and films. People often drop by even when they’re not buying.

Dr. Reiman said she has no conflicts.

SAN FRANCISCO – People who qualify for medical marijuana prescriptions frequently report substituting the substance for their other prescription medications.

In an anonymous survey, 66% of 350 clients at the Berkeley (Calif.) Patients Group, a medical marijuana dispensary, said that they use marijuana as a prescription drug substitute. Their reasons: Cannabis offered better symptom control with fewer side effects than did prescription drugs.

©ron hilton/iStockphoto.com

Those with pain symptoms said that marijuana has less addiction potential than do opioids. Others said marijuana helped to reduce the dose of other medications.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis, and that controls all of those symptoms," said Amanda Reiman, Ph.D., the director of research and social services at the Berkeley center. Almost 50% of those surveyed said they use cannabis two or three times per day.

More than 75% of respondents said they used cannabis for psychiatric disorders, including bipolar disorder, posttraumatic stress disorder, depression, anxiety, and persistent insomnia. Unlike some psychiatric drugs, they said, marijuana didn’t leave them feeling like "zombies," Dr. Reiman reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Almost 70% of those surveyed were men and about 66% were white, in line with the center’s overall demographics. Respondents’ mean age was about 40 years, and ranged from 18 to 81 years. About two-thirds were employed; 81% had at least some college; and 28% made more than $60,000/year. More than half were single.

About 75% had health insurance that covered prescriptions. Even so, "they are still opting to utilize medical cannabis, which is not covered by insurance," Dr. Reiman said.

About 70% said they had a chronic condition, such as diabetes or arthritis. Just over half said they used marijuana for pain relief, including arthritis, migraines, and accident-related injuries. Other uses included appetite stimulation and relief of symptoms from carpal tunnel syndrome and multiple sclerosis.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis."

The amounts used – typically 3-8 g per week – were fairly stable with about 70% reporting no change in marijuana use in the past 6 months. Most "experience a stable level of use throughout their entire course of treatment," Dr. Reiman said.

In operation for 12 years, the Berkeley Patients Group has more than 6,000 patients who pay $15-$60 for one-eighth of an ounce of marijuana – 3.5 grams – depending on strain and potency.

To buy, patients must have a letter from their doctor recommending marijuana for a medical condition. Center staff verifies the letter with a call to the physician. The center obtains the marijuana from its own patients – a must under California law – who grow it and sell it to the dispensary.

Besides smokable marijuana, BPG offers cannabis-laced edibles, capsules, and extract drops to put under the tongue or in tea or coffee, as well as topical marijuana cream for pain and inflammation relief, Dr. Reiman said.

Money remaining after operational costs is used to provide free marijuana to those who couldn’t otherwise afford it, as well as free counseling, message, and other services to BPG members. The dispensary functions more like a community center than a pharmacy, and has a large lounge and regular social events like bingo and films. People often drop by even when they’re not buying.

Dr. Reiman said she has no conflicts.

SAN FRANCISCO – People who qualify for medical marijuana prescriptions frequently report substituting the substance for their other prescription medications.

In an anonymous survey, 66% of 350 clients at the Berkeley (Calif.) Patients Group, a medical marijuana dispensary, said that they use marijuana as a prescription drug substitute. Their reasons: Cannabis offered better symptom control with fewer side effects than did prescription drugs.

©ron hilton/iStockphoto.com

Those with pain symptoms said that marijuana has less addiction potential than do opioids. Others said marijuana helped to reduce the dose of other medications.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis, and that controls all of those symptoms," said Amanda Reiman, Ph.D., the director of research and social services at the Berkeley center. Almost 50% of those surveyed said they use cannabis two or three times per day.

More than 75% of respondents said they used cannabis for psychiatric disorders, including bipolar disorder, posttraumatic stress disorder, depression, anxiety, and persistent insomnia. Unlike some psychiatric drugs, they said, marijuana didn’t leave them feeling like "zombies," Dr. Reiman reported at the American Psychiatric Association’s Institute on Psychiatric Services.

Almost 70% of those surveyed were men and about 66% were white, in line with the center’s overall demographics. Respondents’ mean age was about 40 years, and ranged from 18 to 81 years. About two-thirds were employed; 81% had at least some college; and 28% made more than $60,000/year. More than half were single.

About 75% had health insurance that covered prescriptions. Even so, "they are still opting to utilize medical cannabis, which is not covered by insurance," Dr. Reiman said.

About 70% said they had a chronic condition, such as diabetes or arthritis. Just over half said they used marijuana for pain relief, including arthritis, migraines, and accident-related injuries. Other uses included appetite stimulation and relief of symptoms from carpal tunnel syndrome and multiple sclerosis.

"Instead of having a pain medication, an antianxiety medication, and a sleep medication, they are able to just use cannabis."

The amounts used – typically 3-8 g per week – were fairly stable with about 70% reporting no change in marijuana use in the past 6 months. Most "experience a stable level of use throughout their entire course of treatment," Dr. Reiman said.

In operation for 12 years, the Berkeley Patients Group has more than 6,000 patients who pay $15-$60 for one-eighth of an ounce of marijuana – 3.5 grams – depending on strain and potency.

To buy, patients must have a letter from their doctor recommending marijuana for a medical condition. Center staff verifies the letter with a call to the physician. The center obtains the marijuana from its own patients – a must under California law – who grow it and sell it to the dispensary.

Besides smokable marijuana, BPG offers cannabis-laced edibles, capsules, and extract drops to put under the tongue or in tea or coffee, as well as topical marijuana cream for pain and inflammation relief, Dr. Reiman said.

Money remaining after operational costs is used to provide free marijuana to those who couldn’t otherwise afford it, as well as free counseling, message, and other services to BPG members. The dispensary functions more like a community center than a pharmacy, and has a large lounge and regular social events like bingo and films. People often drop by even when they’re not buying.

Dr. Reiman said she has no conflicts.

SAN DIEGO – The more severe an anterior cruciate ligament injury, the more likely patients are to develop arthritis in the injured knee; structural changes might even be seen within 4 years of the trauma, a small study has shown.

In results presented at the World Congress on Osteoarthritis, patients who had had anterior cruciate ligament (ACL) reconstruction were four times more likely to have abnormal joint space narrowing by then if they also had a defect that extended more than halfway through their femoral cartilage (International Cartilage Repair Society grade III injury), a menisectomy, or both (odds ratio 4.11; 95% confidence interval 1.01-39.55, P = .05).

"These people were highly functioning; they were all athletic people. They had no symptoms of osteoarthritis," said lead investigator Timothy Tourville of the University of Vermont Center for Clinical and Translational Science in Burlington.

"Historically, most studies haven’t been able to demonstrate differences in [less than] 10 or 15 years. I think being able to pick them up at 4 years and identifying those who are at high risk for structural change is very important," rheumatologist David Hunter said in an interview.

"If, at the time of the injury, there is more substantive damage to either [the patient’s] cartilage or their meniscus, you are going to be more cautious about encouraging them to return to high physical activity and potentially redamaging their" knee, said Dr. Hunter, professor of medicine at the University of Sydney (Australia).

The 38 ACL patients in the study, about half women, were under 51 years of age and not obese. Their ACLs were reconstructed within a half-year of their injury, and none had gotten intra-articular injections. Other than their injury, they were in good health with no other joint problems. Baseline radiographs were compared with films at 3-4 years.

More than 60% (8/13) of those with grade III cartilage injuries had abnormal joint space narrowing at that point, compared with 28% (7/25) of those with no more than grade II injuries – defects extending less than halfway through their femoral cartilage – and intact menisci in both compartments.

"Abnormal" meant that the joint space difference between patients’ injured and uninjured knees fell outside the 95% confidence interval of bilateral differences measured in 32 matched controls.

The conference was sponsored by the Osteoarthritis Research Society International. Mr. Tourville and Dr. Hunter said they had no relevant financial disclosures. The National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the work.

SAN DIEGO – The more severe an anterior cruciate ligament injury, the more likely patients are to develop arthritis in the injured knee; structural changes might even be seen within 4 years of the trauma, a small study has shown.

In results presented at the World Congress on Osteoarthritis, patients who had had anterior cruciate ligament (ACL) reconstruction were four times more likely to have abnormal joint space narrowing by then if they also had a defect that extended more than halfway through their femoral cartilage (International Cartilage Repair Society grade III injury), a menisectomy, or both (odds ratio 4.11; 95% confidence interval 1.01-39.55, P = .05).

"These people were highly functioning; they were all athletic people. They had no symptoms of osteoarthritis," said lead investigator Timothy Tourville of the University of Vermont Center for Clinical and Translational Science in Burlington.

"Historically, most studies haven’t been able to demonstrate differences in [less than] 10 or 15 years. I think being able to pick them up at 4 years and identifying those who are at high risk for structural change is very important," rheumatologist David Hunter said in an interview.

"If, at the time of the injury, there is more substantive damage to either [the patient’s] cartilage or their meniscus, you are going to be more cautious about encouraging them to return to high physical activity and potentially redamaging their" knee, said Dr. Hunter, professor of medicine at the University of Sydney (Australia).

The 38 ACL patients in the study, about half women, were under 51 years of age and not obese. Their ACLs were reconstructed within a half-year of their injury, and none had gotten intra-articular injections. Other than their injury, they were in good health with no other joint problems. Baseline radiographs were compared with films at 3-4 years.

More than 60% (8/13) of those with grade III cartilage injuries had abnormal joint space narrowing at that point, compared with 28% (7/25) of those with no more than grade II injuries – defects extending less than halfway through their femoral cartilage – and intact menisci in both compartments.

"Abnormal" meant that the joint space difference between patients’ injured and uninjured knees fell outside the 95% confidence interval of bilateral differences measured in 32 matched controls.

The conference was sponsored by the Osteoarthritis Research Society International. Mr. Tourville and Dr. Hunter said they had no relevant financial disclosures. The National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the work.

SAN DIEGO – The more severe an anterior cruciate ligament injury, the more likely patients are to develop arthritis in the injured knee; structural changes might even be seen within 4 years of the trauma, a small study has shown.

In results presented at the World Congress on Osteoarthritis, patients who had had anterior cruciate ligament (ACL) reconstruction were four times more likely to have abnormal joint space narrowing by then if they also had a defect that extended more than halfway through their femoral cartilage (International Cartilage Repair Society grade III injury), a menisectomy, or both (odds ratio 4.11; 95% confidence interval 1.01-39.55, P = .05).

"These people were highly functioning; they were all athletic people. They had no symptoms of osteoarthritis," said lead investigator Timothy Tourville of the University of Vermont Center for Clinical and Translational Science in Burlington.

"Historically, most studies haven’t been able to demonstrate differences in [less than] 10 or 15 years. I think being able to pick them up at 4 years and identifying those who are at high risk for structural change is very important," rheumatologist David Hunter said in an interview.

"If, at the time of the injury, there is more substantive damage to either [the patient’s] cartilage or their meniscus, you are going to be more cautious about encouraging them to return to high physical activity and potentially redamaging their" knee, said Dr. Hunter, professor of medicine at the University of Sydney (Australia).

The 38 ACL patients in the study, about half women, were under 51 years of age and not obese. Their ACLs were reconstructed within a half-year of their injury, and none had gotten intra-articular injections. Other than their injury, they were in good health with no other joint problems. Baseline radiographs were compared with films at 3-4 years.

More than 60% (8/13) of those with grade III cartilage injuries had abnormal joint space narrowing at that point, compared with 28% (7/25) of those with no more than grade II injuries – defects extending less than halfway through their femoral cartilage – and intact menisci in both compartments.

"Abnormal" meant that the joint space difference between patients’ injured and uninjured knees fell outside the 95% confidence interval of bilateral differences measured in 32 matched controls.

The conference was sponsored by the Osteoarthritis Research Society International. Mr. Tourville and Dr. Hunter said they had no relevant financial disclosures. The National Institute of Arthritis and Musculoskeletal and Skin Diseases supported the work.

SAN DIEGO – Structural damage due to osteoarthritis appears to be more common, and more severe, in the patellofemoral joint than in the tibiofemoral joint, making the patellofemoral joint the predominant one affected by knee osteoarthritis, according to findings from a magnetic resonance imaging–based study involving nearly 1,000 people.

It’s important that future research "not only address the tibiofemoral joint, but also the patellofemoral joint," said lead investigator Joshua Stefanik, Ph.D., a research associate in Boston University’s Clinical Epidemiology, Research, and Training Unit, said at the World Congress on Osteoarthritis.

The findings are surprising because "historically, everybody focuses on the tibiofemoral joint. We are probably missing a lot of disease" by relying on radiographs and clinical exams for diagnosis; they aren’t very good at picking up problems in the patellofemoral joint (PFJ), said Dr. David Hunter in an interview.

But even if it does a better job, "I wouldn’t encourage people to do an MRI if they have knee osteoarthritis." The results won’t change clinical management, and if meniscal tears are found, patients may end up in the operating room having an unnecessary meniscectomy, "which doesn’t do them any favors. Typically, the meniscus isn’t the problem." Tears are common and generally asymptomatic, said Dr. Hunter, a professor of medicine at the University of Sydney.

"Once clinicians are better educated about [such] dangers, MRI may be a good way to pick up [PFJ] disease," he said. Patellofemoral braces and PFJ-modifying shoe inserts are among the management options.

The 970 subjects in the study were part of the Framingham (Mass.) Osteoarthritis Study and were recruited from that community without regards to knee pain or osteoarthritis. Their mean age was 63.4 years and mean body mass index was 28.6 kg/m²; 57% were women, and 22% complained of knee pain. Cases of inflammatory arthritis were excluded. One knee was studied in each patient.

Radiographs found tibiofemoral joint (TFJ) damage in 11.9% of subjects, PFJ damage in just 1.4%, and damage in both joints in 5.9%.

The prevalence of PFJ problems was much higher on MRI; 20.4% had PFJ cartilage damage (WORMS [Whole-Organ Magnetic Resonance Imaging Score] greater than or equal to 2); 10.4% TFJ damage; and 44.2% damage in both joints. When both joints were involved, the most severe lesions were usually in the PFJ.

Similarly, 18.6% of subjects had PFJ cartilage damage extending down to bone (WORMS 2.5, greater than or equal to 5); 8% had TFJ damage down to bone; and 7.8% damage down to the bone in both joints.

The team found PFJ bone marrow lesions (WORMS greater than or equal to 1) in 17.9% of subjects; TFJ lesions in 16.5%; and lesions in both joints in 21.8%. Again, the most severe lesions were usually in the PFJ.

Finally, 15.2% of the Framingham subjects had both bone marrow lesions and cartilage damage down to bone in their PFJs, while only 8.8% had both problems in their TFJs; 4.4% had them in both joints.

Patterns were similar for men and women, and in knees with pain. The researchers used 1.5 T MRI with turbo spin-echo, fat-suppressed images in the sagittal, coronal, and axial planes.

The congress was sponsored by the Osteoarthritis Research Society International. Dr. Stefanik and Dr. Hunter reported no financial disclosures. The National Institutes of Health and the Arthritis Foundation funded the work.

SAN DIEGO – Structural damage due to osteoarthritis appears to be more common, and more severe, in the patellofemoral joint than in the tibiofemoral joint, making the patellofemoral joint the predominant one affected by knee osteoarthritis, according to findings from a magnetic resonance imaging–based study involving nearly 1,000 people.

It’s important that future research "not only address the tibiofemoral joint, but also the patellofemoral joint," said lead investigator Joshua Stefanik, Ph.D., a research associate in Boston University’s Clinical Epidemiology, Research, and Training Unit, said at the World Congress on Osteoarthritis.

The findings are surprising because "historically, everybody focuses on the tibiofemoral joint. We are probably missing a lot of disease" by relying on radiographs and clinical exams for diagnosis; they aren’t very good at picking up problems in the patellofemoral joint (PFJ), said Dr. David Hunter in an interview.

But even if it does a better job, "I wouldn’t encourage people to do an MRI if they have knee osteoarthritis." The results won’t change clinical management, and if meniscal tears are found, patients may end up in the operating room having an unnecessary meniscectomy, "which doesn’t do them any favors. Typically, the meniscus isn’t the problem." Tears are common and generally asymptomatic, said Dr. Hunter, a professor of medicine at the University of Sydney.

"Once clinicians are better educated about [such] dangers, MRI may be a good way to pick up [PFJ] disease," he said. Patellofemoral braces and PFJ-modifying shoe inserts are among the management options.

The 970 subjects in the study were part of the Framingham (Mass.) Osteoarthritis Study and were recruited from that community without regards to knee pain or osteoarthritis. Their mean age was 63.4 years and mean body mass index was 28.6 kg/m²; 57% were women, and 22% complained of knee pain. Cases of inflammatory arthritis were excluded. One knee was studied in each patient.

Radiographs found tibiofemoral joint (TFJ) damage in 11.9% of subjects, PFJ damage in just 1.4%, and damage in both joints in 5.9%.

The prevalence of PFJ problems was much higher on MRI; 20.4% had PFJ cartilage damage (WORMS [Whole-Organ Magnetic Resonance Imaging Score] greater than or equal to 2); 10.4% TFJ damage; and 44.2% damage in both joints. When both joints were involved, the most severe lesions were usually in the PFJ.

Similarly, 18.6% of subjects had PFJ cartilage damage extending down to bone (WORMS 2.5, greater than or equal to 5); 8% had TFJ damage down to bone; and 7.8% damage down to the bone in both joints.

The team found PFJ bone marrow lesions (WORMS greater than or equal to 1) in 17.9% of subjects; TFJ lesions in 16.5%; and lesions in both joints in 21.8%. Again, the most severe lesions were usually in the PFJ.

Finally, 15.2% of the Framingham subjects had both bone marrow lesions and cartilage damage down to bone in their PFJs, while only 8.8% had both problems in their TFJs; 4.4% had them in both joints.

Patterns were similar for men and women, and in knees with pain. The researchers used 1.5 T MRI with turbo spin-echo, fat-suppressed images in the sagittal, coronal, and axial planes.

The congress was sponsored by the Osteoarthritis Research Society International. Dr. Stefanik and Dr. Hunter reported no financial disclosures. The National Institutes of Health and the Arthritis Foundation funded the work.

SAN DIEGO – Structural damage due to osteoarthritis appears to be more common, and more severe, in the patellofemoral joint than in the tibiofemoral joint, making the patellofemoral joint the predominant one affected by knee osteoarthritis, according to findings from a magnetic resonance imaging–based study involving nearly 1,000 people.

It’s important that future research "not only address the tibiofemoral joint, but also the patellofemoral joint," said lead investigator Joshua Stefanik, Ph.D., a research associate in Boston University’s Clinical Epidemiology, Research, and Training Unit, said at the World Congress on Osteoarthritis.

The findings are surprising because "historically, everybody focuses on the tibiofemoral joint. We are probably missing a lot of disease" by relying on radiographs and clinical exams for diagnosis; they aren’t very good at picking up problems in the patellofemoral joint (PFJ), said Dr. David Hunter in an interview.

But even if it does a better job, "I wouldn’t encourage people to do an MRI if they have knee osteoarthritis." The results won’t change clinical management, and if meniscal tears are found, patients may end up in the operating room having an unnecessary meniscectomy, "which doesn’t do them any favors. Typically, the meniscus isn’t the problem." Tears are common and generally asymptomatic, said Dr. Hunter, a professor of medicine at the University of Sydney.

"Once clinicians are better educated about [such] dangers, MRI may be a good way to pick up [PFJ] disease," he said. Patellofemoral braces and PFJ-modifying shoe inserts are among the management options.

The 970 subjects in the study were part of the Framingham (Mass.) Osteoarthritis Study and were recruited from that community without regards to knee pain or osteoarthritis. Their mean age was 63.4 years and mean body mass index was 28.6 kg/m²; 57% were women, and 22% complained of knee pain. Cases of inflammatory arthritis were excluded. One knee was studied in each patient.

Radiographs found tibiofemoral joint (TFJ) damage in 11.9% of subjects, PFJ damage in just 1.4%, and damage in both joints in 5.9%.

The prevalence of PFJ problems was much higher on MRI; 20.4% had PFJ cartilage damage (WORMS [Whole-Organ Magnetic Resonance Imaging Score] greater than or equal to 2); 10.4% TFJ damage; and 44.2% damage in both joints. When both joints were involved, the most severe lesions were usually in the PFJ.

Similarly, 18.6% of subjects had PFJ cartilage damage extending down to bone (WORMS 2.5, greater than or equal to 5); 8% had TFJ damage down to bone; and 7.8% damage down to the bone in both joints.

The team found PFJ bone marrow lesions (WORMS greater than or equal to 1) in 17.9% of subjects; TFJ lesions in 16.5%; and lesions in both joints in 21.8%. Again, the most severe lesions were usually in the PFJ.

Finally, 15.2% of the Framingham subjects had both bone marrow lesions and cartilage damage down to bone in their PFJs, while only 8.8% had both problems in their TFJs; 4.4% had them in both joints.

Patterns were similar for men and women, and in knees with pain. The researchers used 1.5 T MRI with turbo spin-echo, fat-suppressed images in the sagittal, coronal, and axial planes.

The congress was sponsored by the Osteoarthritis Research Society International. Dr. Stefanik and Dr. Hunter reported no financial disclosures. The National Institutes of Health and the Arthritis Foundation funded the work.

SAN DIEGO – To at least some extent, findings seen on magnetic resonance imaging indicate the source of pain in osteoarthritic knees, according to University of Pittsburgh researchers.

Medial joint line knee pain, they found, is associated with bone marrow lesions in the medial compartment. Medial regional knee pain is associated with medial bone marrow lesions, meniscal extrusions, and meniscal damage, according to Dr. Kent Kwoh, a professor in the division of rheumatology and clinical immunology at the University of Pittsburgh.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there."

There were trends, as well, including one toward lateral regional knee pain being associated with lateral meniscal extrusions, but they didn’t reach statistical significance, probably because of the small number of patients in the trial with lateral regional pain and other specific findings, he said.

Nonetheless, the findings mean that "the location of pain is where the pathology is. We haven’t known that. It’s an important observation," said Dr. David Felson after Dr. Kwoh’s presentation.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there, and that you can diminish the pain and perhaps help the pathology by focusing on the biomechanical abnormalities," with bracing, wedging, or other targeted interventions, said Dr. Felson, a professor of medicine and epidemiology at Boston University. He also is director of the Research in Osteoarthritis in Manchester (ROAM) group the University of Manchester (England).

The 177 subjects in the study had mild to moderate pain on most days. Their age averaged 52 years, their mean body mass index was 29 kg/m², and 46% were women. Half had medial joint space narrowing, and about 20% had lateral joint space narrowing. Slightly more than half had medial osteophytes, and slightly less than half had lateral osteophytes.

The Pittsburgh team used MRI to look at where patients said it hurt, or the general region if they could not point to the exact place.

The relative risk ratio for medial bone marrow lesions in the 83 patients with local medial joint line pain was 9.89. The risk ratios for medial bone marrow lesions, meniscal damage, and meniscal extrusion in the 36 patients with regional medial pain were 12.10, 3.72, and 8.77, respectively. The findings were statistically significant.

Right knee medial joint line pain and right knee lateral joint line pain with patellar and medial joint line components were the most common localizable pain types. Left knee patellar and left knee medial pain were the most common regional types.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Kwoh and Dr. Felson said they have no disclosures. The University of Pittsburgh and Coca-Cola Co.’s Beverage Institute paid for the work.

SAN DIEGO – To at least some extent, findings seen on magnetic resonance imaging indicate the source of pain in osteoarthritic knees, according to University of Pittsburgh researchers.

Medial joint line knee pain, they found, is associated with bone marrow lesions in the medial compartment. Medial regional knee pain is associated with medial bone marrow lesions, meniscal extrusions, and meniscal damage, according to Dr. Kent Kwoh, a professor in the division of rheumatology and clinical immunology at the University of Pittsburgh.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there."

There were trends, as well, including one toward lateral regional knee pain being associated with lateral meniscal extrusions, but they didn’t reach statistical significance, probably because of the small number of patients in the trial with lateral regional pain and other specific findings, he said.

Nonetheless, the findings mean that "the location of pain is where the pathology is. We haven’t known that. It’s an important observation," said Dr. David Felson after Dr. Kwoh’s presentation.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there, and that you can diminish the pain and perhaps help the pathology by focusing on the biomechanical abnormalities," with bracing, wedging, or other targeted interventions, said Dr. Felson, a professor of medicine and epidemiology at Boston University. He also is director of the Research in Osteoarthritis in Manchester (ROAM) group the University of Manchester (England).

The 177 subjects in the study had mild to moderate pain on most days. Their age averaged 52 years, their mean body mass index was 29 kg/m², and 46% were women. Half had medial joint space narrowing, and about 20% had lateral joint space narrowing. Slightly more than half had medial osteophytes, and slightly less than half had lateral osteophytes.

The Pittsburgh team used MRI to look at where patients said it hurt, or the general region if they could not point to the exact place.

The relative risk ratio for medial bone marrow lesions in the 83 patients with local medial joint line pain was 9.89. The risk ratios for medial bone marrow lesions, meniscal damage, and meniscal extrusion in the 36 patients with regional medial pain were 12.10, 3.72, and 8.77, respectively. The findings were statistically significant.

Right knee medial joint line pain and right knee lateral joint line pain with patellar and medial joint line components were the most common localizable pain types. Left knee patellar and left knee medial pain were the most common regional types.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Kwoh and Dr. Felson said they have no disclosures. The University of Pittsburgh and Coca-Cola Co.’s Beverage Institute paid for the work.

SAN DIEGO – To at least some extent, findings seen on magnetic resonance imaging indicate the source of pain in osteoarthritic knees, according to University of Pittsburgh researchers.

Medial joint line knee pain, they found, is associated with bone marrow lesions in the medial compartment. Medial regional knee pain is associated with medial bone marrow lesions, meniscal extrusions, and meniscal damage, according to Dr. Kent Kwoh, a professor in the division of rheumatology and clinical immunology at the University of Pittsburgh.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there."

There were trends, as well, including one toward lateral regional knee pain being associated with lateral meniscal extrusions, but they didn’t reach statistical significance, probably because of the small number of patients in the trial with lateral regional pain and other specific findings, he said.

Nonetheless, the findings mean that "the location of pain is where the pathology is. We haven’t known that. It’s an important observation," said Dr. David Felson after Dr. Kwoh’s presentation.

"If you have pain on the inner side of your knee, and you’re biomechanically loading that side too much, you [know] that there’s pathology there, and that you can diminish the pain and perhaps help the pathology by focusing on the biomechanical abnormalities," with bracing, wedging, or other targeted interventions, said Dr. Felson, a professor of medicine and epidemiology at Boston University. He also is director of the Research in Osteoarthritis in Manchester (ROAM) group the University of Manchester (England).

The 177 subjects in the study had mild to moderate pain on most days. Their age averaged 52 years, their mean body mass index was 29 kg/m², and 46% were women. Half had medial joint space narrowing, and about 20% had lateral joint space narrowing. Slightly more than half had medial osteophytes, and slightly less than half had lateral osteophytes.

The Pittsburgh team used MRI to look at where patients said it hurt, or the general region if they could not point to the exact place.

The relative risk ratio for medial bone marrow lesions in the 83 patients with local medial joint line pain was 9.89. The risk ratios for medial bone marrow lesions, meniscal damage, and meniscal extrusion in the 36 patients with regional medial pain were 12.10, 3.72, and 8.77, respectively. The findings were statistically significant.

Right knee medial joint line pain and right knee lateral joint line pain with patellar and medial joint line components were the most common localizable pain types. Left knee patellar and left knee medial pain were the most common regional types.

The congress was sponsored by the Osteoarthritis Research Society International.

Dr. Kwoh and Dr. Felson said they have no disclosures. The University of Pittsburgh and Coca-Cola Co.’s Beverage Institute paid for the work.

SAN DIEGO – Even older, heavier, sicker patients, and those with worse mental health, benefit substantially from total hip replacement when indicated, a study has shown.

It’s just that their outcomes aren’t quite as good as those of their younger, leaner, and healthier peers because they also tend to start out with worse preoperative hip pain and function. Even so, they benefit about as much from the operation, gaining in the range of 20 points on the 48-point Oxford Hip Score (OHS), the study found.

Because of that, perhaps physicians should reconsider basing selection of surgery candidates on negative preoperative characteristics; maybe even "patient [body mass index (BMI)] should not be used, as these patients still get substantial improvement following surgery," lead investigator Andy Judge, Ph.D., said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.

The team compared preoperative OHS scores with postoperative scores collected over a 5-year period from 1,375 hip replacement patients who underwent surgery because of osteoarthritis. Each got a cemented Exeter femoral component. Their mean age was 68; 60% were women.

The OHS asks patients 12 multiple-choice questions about pain and function. The five possible answers are scored 0-4, with 0 being the worst possible overall score, and 48 the best.

In general, and regardless of preoperative factors, surgery gave the majority of patients significant relief in the 1st year that was maintained through the 5th year, said Dr. Judge, a senior statistician at the University of Oxford.

There were "small differences in postoperative OHS observed for age, BMI, comorbidity, mental health, and femoral component size, but these patients still received substantial benefit from surgery," he said.

Preoperative hip pain and function was the biggest predictor of how patients fared after the operation. Patients with worse scores tended to have worse postoperative pain and function.

However, even those who entered the operating room with OHS scores below 5 improved, on average, to about 30. Those who entered with scores in the mid-30s improved to the low 40s.

Between-group magnitudes of improvement were similar for other factors taken into account. For instance, average preoperative OHS scores were in the lower teens for those with BMIs at or above 30 kg/m²; postoperative scores were in the mid-30s. Slimmer peers with BMIs below 30 kg/m² entered the operating room with average OHS scores in the upper teens; their postoperative scores improved to about 40 on average.

It was the same story with poorer preoperative mental health scores and higher numbers of comorbidities; patients started and wound up a few points lower on the OHS, but tended to benefit about as much as patients with better mental health and fewer comorbidities.

Patients who were 60-70 years old had the best postoperative scores by a few points, but also started with OHS scores a few points higher than younger and older patients, who, nonetheless, had comparable, roughly 20-point improvements in postoperative OHS scores.

Similarly, patients with larger femoral component sizes (offset of 44 mm or more) also had slightly better outcomes, but also entered the trial with slightly better hip scores. The trial’s findings were statistically significant.

Dr. Judge said he had no relevant financial disclosures. The study was funded by the British National Institute for Health Research.

SAN DIEGO – Even older, heavier, sicker patients, and those with worse mental health, benefit substantially from total hip replacement when indicated, a study has shown.

It’s just that their outcomes aren’t quite as good as those of their younger, leaner, and healthier peers because they also tend to start out with worse preoperative hip pain and function. Even so, they benefit about as much from the operation, gaining in the range of 20 points on the 48-point Oxford Hip Score (OHS), the study found.

Because of that, perhaps physicians should reconsider basing selection of surgery candidates on negative preoperative characteristics; maybe even "patient [body mass index (BMI)] should not be used, as these patients still get substantial improvement following surgery," lead investigator Andy Judge, Ph.D., said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.

The team compared preoperative OHS scores with postoperative scores collected over a 5-year period from 1,375 hip replacement patients who underwent surgery because of osteoarthritis. Each got a cemented Exeter femoral component. Their mean age was 68; 60% were women.

The OHS asks patients 12 multiple-choice questions about pain and function. The five possible answers are scored 0-4, with 0 being the worst possible overall score, and 48 the best.

In general, and regardless of preoperative factors, surgery gave the majority of patients significant relief in the 1st year that was maintained through the 5th year, said Dr. Judge, a senior statistician at the University of Oxford.

There were "small differences in postoperative OHS observed for age, BMI, comorbidity, mental health, and femoral component size, but these patients still received substantial benefit from surgery," he said.

Preoperative hip pain and function was the biggest predictor of how patients fared after the operation. Patients with worse scores tended to have worse postoperative pain and function.

However, even those who entered the operating room with OHS scores below 5 improved, on average, to about 30. Those who entered with scores in the mid-30s improved to the low 40s.

Between-group magnitudes of improvement were similar for other factors taken into account. For instance, average preoperative OHS scores were in the lower teens for those with BMIs at or above 30 kg/m²; postoperative scores were in the mid-30s. Slimmer peers with BMIs below 30 kg/m² entered the operating room with average OHS scores in the upper teens; their postoperative scores improved to about 40 on average.

It was the same story with poorer preoperative mental health scores and higher numbers of comorbidities; patients started and wound up a few points lower on the OHS, but tended to benefit about as much as patients with better mental health and fewer comorbidities.

Patients who were 60-70 years old had the best postoperative scores by a few points, but also started with OHS scores a few points higher than younger and older patients, who, nonetheless, had comparable, roughly 20-point improvements in postoperative OHS scores.

Similarly, patients with larger femoral component sizes (offset of 44 mm or more) also had slightly better outcomes, but also entered the trial with slightly better hip scores. The trial’s findings were statistically significant.

Dr. Judge said he had no relevant financial disclosures. The study was funded by the British National Institute for Health Research.

SAN DIEGO – Even older, heavier, sicker patients, and those with worse mental health, benefit substantially from total hip replacement when indicated, a study has shown.

It’s just that their outcomes aren’t quite as good as those of their younger, leaner, and healthier peers because they also tend to start out with worse preoperative hip pain and function. Even so, they benefit about as much from the operation, gaining in the range of 20 points on the 48-point Oxford Hip Score (OHS), the study found.

Because of that, perhaps physicians should reconsider basing selection of surgery candidates on negative preoperative characteristics; maybe even "patient [body mass index (BMI)] should not be used, as these patients still get substantial improvement following surgery," lead investigator Andy Judge, Ph.D., said at the World Congress on Osteoarthritis, sponsored by Osteoarthritis Research Society International.

The team compared preoperative OHS scores with postoperative scores collected over a 5-year period from 1,375 hip replacement patients who underwent surgery because of osteoarthritis. Each got a cemented Exeter femoral component. Their mean age was 68; 60% were women.

The OHS asks patients 12 multiple-choice questions about pain and function. The five possible answers are scored 0-4, with 0 being the worst possible overall score, and 48 the best.

In general, and regardless of preoperative factors, surgery gave the majority of patients significant relief in the 1st year that was maintained through the 5th year, said Dr. Judge, a senior statistician at the University of Oxford.

There were "small differences in postoperative OHS observed for age, BMI, comorbidity, mental health, and femoral component size, but these patients still received substantial benefit from surgery," he said.

Preoperative hip pain and function was the biggest predictor of how patients fared after the operation. Patients with worse scores tended to have worse postoperative pain and function.

However, even those who entered the operating room with OHS scores below 5 improved, on average, to about 30. Those who entered with scores in the mid-30s improved to the low 40s.

Between-group magnitudes of improvement were similar for other factors taken into account. For instance, average preoperative OHS scores were in the lower teens for those with BMIs at or above 30 kg/m²; postoperative scores were in the mid-30s. Slimmer peers with BMIs below 30 kg/m² entered the operating room with average OHS scores in the upper teens; their postoperative scores improved to about 40 on average.

It was the same story with poorer preoperative mental health scores and higher numbers of comorbidities; patients started and wound up a few points lower on the OHS, but tended to benefit about as much as patients with better mental health and fewer comorbidities.

Patients who were 60-70 years old had the best postoperative scores by a few points, but also started with OHS scores a few points higher than younger and older patients, who, nonetheless, had comparable, roughly 20-point improvements in postoperative OHS scores.

Similarly, patients with larger femoral component sizes (offset of 44 mm or more) also had slightly better outcomes, but also entered the trial with slightly better hip scores. The trial’s findings were statistically significant.

Dr. Judge said he had no relevant financial disclosures. The study was funded by the British National Institute for Health Research.